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Chapter 14

Infection and Inflammation

Infection is one of the 10 most common causes of death in older adults.

The presentation of infections in older adults is often masked, which can lead to delayed treatment.

The immune system enables the body to defend itself against disease-causing microorganisms and other foreign bodies.

With aging the immune system exhibits a diminished ability to provide such protection.

Introduction

For infection to occur, there must be a reservoir of an infectious disease, a portal of entry, and a susceptible host.

Source may be a person’s own microbial flora (endogenous) or something in the environment (exogenous).

Nosocomial infections: acquired in the hospital

Community acquired: acquired outside the health care facility

The Chain of Infection

Changes in both cell-mediated and antibody-mediated immune response

Atrophy of the thymus

Diminished cellular (T cell–mediated) and humoral (B-lymphocyte) immunity

Production of autoantibodies increases

Skin becomes more fragile and prone to breakdown or abrasion.

Age-Related Changes in the Immune System

Nutritional factors

Malnutrition

Iron and trace element deficiency

Psychosocial factors

Depression

Drugs

Complementary and alternative medications

Factors Affecting Immunocompetence

Every adult over the age of 65 should receive the influenza vaccination annually.

Community-acquired pneumonia is caused by multiple pathogens.

Pneumococcal vaccine is recommended for everyone over the age of 65.

Infection control measures help to reduce the risk of illness.

Many older adults present with atypical or diminished signs and symptoms.

Influenza and Pneumonia

Neoplasms occur with greater frequency in older adults.

Common types include lung cancer, breast cancer, and prostate cancer.

Presence of the cancer reveals presence of decreased immune response.

Cancer and cancer treatment can induce additional immune deficits.

Cancer

Symptoms: extreme fatigue, painful or swollen joints, unexplained fever, skin rashes, and kidney problems

Management objective is to control the severity of symptoms and prevent a flare.

Avoiding the sun, exercising, complying with drugs, limiting stress, and having regular health care visits

Systemic Lupus Erythematosus

Inflammatory polyarthritis of unknown cause

Symptoms: morning stiffness lasting for hours, tenderness, pain on motion, limited range of motion, and joint deformity in the small joints of the hands and feet

Treatment: physical therapy, first-line drugs for RA are nonsteroidal antiinflammatory drugs (NSAIDs), second-line drugs are known as disease-modifying antirheumatic drugs (DMARDs)

Rheumatoid Arthritis

Underrecognized problem among the older adult population: 31% of persons living with HIV and 17% of newly diagnosed cases are in those over the age of 50

The low clinical suspicion of HIV infection and delayed recognition of AIDS-defining infections contribute to the poor prognosis of HIV infection in older adults.

In older adults there is only a short interval from HIV infection to the development of AIDS and death.

Sex education, the use of condoms, and how and when to take an HIV test should be taught to older adults.

HIV in Older Adults

Nosocomial pathogen transmitted person to person, primarily from the hands of health care workers

Occurs when organism is present and normal flora of bowel are disturbed

The hallmark diarrhea is caused by a motility-altering factor that stimulates muscle contractions.

Consistent hand washing between contacts with patients and the use of gloves when handling body substances such as feces

Treatment: discontinue current antibiotic therapy, then treatment with oral vancomycin or fidaxomicin

Clostridium difficile

Risk factors: age more than 65 years, antimicrobial therapy, chronic renal failure, serious illness, and prolonged hospitalization

Transmitted person to person via hands of health care workers

Dedicated equipment, private rooms, and barrier precautions

Symptomatic patients should be treated with antibiotics indicated through culture and sensitivity.

Vancomycin-Resistant Enterococcus (VRE)

Transmitted patient to patient via hands of health care workers

Risk factors: insulin-dependent diabetes mellitus, chronic hemodialysis, illicit intravenous drug use, prolonged hospitalization, prolonged antibiotic therapy, stays in the intensive care unit, burn unit, or with an infected patient

Private room and barrier protection

Symptomatic patients should be treated with antibiotics indicated through culture and sensitivity.

Methicillin-Resistant Staphylococcus Aureus (MRSA)

May not exhibit classic symptoms of infection

Fever—temperature increase may be limited, or no increase may occur at all, so low-grade fever must be taken seriously.

Changes in the behavior: increased malaise or fatigue, combined with other symptoms may indicate the onset of infection.

Fever and inflammation may be reduced, whereas the white blood cell (WBC) count may still reflect an increased value.

History of infections, current disease processes, and medications especially antiinflammatory and immunosuppressant drugs

Infection Nursing Management: Assessment

The risk factors determined during the assessment indicate potential nursing diagnoses

Inadequate nutrition

Potential for infection

Need for health teaching due to knowledge deficits of immunizations, nutrition, or protection against infection from oneself or others

Reduced social interaction associated with infection and immune status

Infection Nursing Management: Diagnosis

The nurse just admitted an older adult with new onset confusion and cough. The family states that the condition came on suddenly. The nurse completes a history and physical assessment on the patient. Discuss the following assessment findings, and state whether or not they are significant and why.

1. History of RA and taking low-dose prednisone

2. White blood cell count is 8.9.

3. Lives in a senior house and dines with other residents

4. Temperature is 99.8°F.

5. Last pneumonia vaccine was 5 years ago.

Quick Quiz!

ANS:

1. History of RA and taking low-dose prednisone

Immune function is already compromised by rheumatoid arthritis and steroids.

2. White blood cell count is 8.9.

Older adults may not have elevated WBC when infection is present.

Answer to Quick Quiz (1 of 2)

3. Lives in a senior house and dines with other residents

Living in close quarters with others puts older adults at risk for infectious disease.

4. Temperature is 99.8°F.

Fever may not be present.

5. Last pneumonia vaccine was 5 years ago.

Pneumonia vaccine should be administered every 5 years in patients with chronic illness.

Answer to Quick Quiz (2 of 2)

The patient with increased risk for infection will:

Avoiding primary or secondary infection

Maintaining or improving immune status

The patient will do the following:

Increase knowledge in areas related to infection prevention, maintenance of immune status, and health practices

Consumes a well-balanced, high-caloric diet on daily basis

Performs self-care activities with minimum energy expenditure and risk of injury

Infection Nursing Management: Planning and Expected Outcomes

Prevent exposure to infections

Enhance immune system to enable patients to better resist infections

Optimum nutritional status is important.

Resolve detected deficiencies

Meals on wheels, assistance with food preparation, or ability to visit a senior center nutrition site

Nursing Interventions

Based on patients’ responses in meeting their goals and outcomes

One standard for evaluation is whether a patient contracts an infection.

Evaluation